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* 1. Which county are you currently living in?

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* 2. What is your age group?

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* 3. Where are you living?

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* 4. What is the longest time you have ever stayed in stable permanent housing?

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* 5. Why did you leave that housing?

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* 6. Please identify the degree to which the following barriers have prevent(ed) you from obtaining permanent housing:

  Not a barrier Minor barrier Moderate barrier Severe barrier
Transportation
Physical access
Rent too expensive
Poor credit
Bad landlord references
Mental Illness
Domestic violence
Not enough money
No childcare
Lack of services
No employment
Criminal History
Alcohol or drug use
Discrimination
Other

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* 7. What services or resources have been most helpful to you in getting and/or keeping housing?

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